6 June 2008

Doppelgänger Fee Schedule

I’m thinking more about focusing a psychological practice on people who “have issues” with their work. As anyone who’s followed my angsty musings on this blog can attest, I have my own issues with work. One of the big ones is how to evaluate the monetary value of what I do, or of what anyone does for that matter. Is it what I think it’s worth? Is it what the labor market would bear for a person of my skills, experience, etc.? Or is it the value others derive from my efforts?

I can go about it the usual way, the way I’ve done it before: find out what psychologists, therapists, analysts, etc. charge by the hour in my town and pick a number on that basis. Some practitioners have a sliding scale based on the client’s ability to pay, kind of like the progressive taxation strategy of liberal democracy. Both of these approaches blur all qualitative distinctions between practitioners and praxes. More importantly, this sort of fee structure says nothing about use value to the client. Having read N. Pepperell’s neo-Marxist musings on use value as what will have been, though, I’d have to wait to see how my clients value my services over time before I could arrive at an appropriate fee.

On a walk this morning I had a new idea. What if I charge clients the same amount they earn? This way I ignore market considerations and use value and affordability scales. I also avoid status differentials between myself and my clients. If you’re my client, my financial value is identical to your own. Work-wise I am your economic double. Take your annual pay, divide it by 2,000, and pay me that amount per hour. If you make $40K per year, pay me $20/hour; if you make $1million per year, pay me $500/hour. If you start losing money because of my subversive interventions, I take a financial hit right along with you.

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The scheme is now tied to how the market values your clients, and is that in any way a better yardstick than those that you reject?

Is it that important to have structured your fees before diving into the practice? Perhaps the question can be deferred and you will have a clearer idea of what your practice will be worth. The proof may be in the pudding but in the meantime there seems no great harm in starting with the existing ‘average market’ value and then adjusting as you find appropriate from your experience.

“Is it that important to have structured your fees before diving into the practice?”

When it comes down to it Sam, I’m probably more interested in the praxis than in actually practicing. If I’m going to focus on work-related issues, then I think it’s fair to say that the economics of work is a very significant issue indeed. Here’s a brief review of the issue of fees for therapists and analysts. Freud thought that paying more to your analyst made you value the service more, which in turn would increase the effectiveness of treatment. The higher the fee, presumably, the better the quality of the analysis. In this formulation use value results from price rather than vice versa.

I don’t know how it works in India or Australia, but in the US most people pay either all or part of the fees for psychological services, with insurance covering either a portion of the fee or nothing at all. Now I suppose I should support the 3rd party payment scheme, which as you say takes things at least part of the way out of marketplace considerations. But the “mental health benefit” is based on the premise that psychological issues are a kind of illness to be treated.

I’m not particularly interested in offering work-related therapy; e.g., getting people to deal with their work stress so they can get back on the job more quickly. I prefer a more analytical approach: work-induced anxiety is an indicator that there’s some mismatch between your working self and something else about yourself that you’ve repressed. I’m not looking for a hidden mental illness, but rather for something that’s wrong about the job itself, something you’re trying not to acknowledge. The 3rd-party payer is usually an employer, so there’s an implicit buy-in to the idea that work stress is a problem in the worker’s head rather than in the job or the economy. This is like war-related stress which is the subject of today’s post.

The issue of fees is important not just to me personally but to the praxis. I want to call attention to the market value of work, to the relationship between pay and value, which very well may be “out ,of joint” for most people. If I “take use value and exchange value as I find them” — i.e., if I operate within the price structure already established by the marketplace for psych services, then I’m acting as if this structure is “real,” inherent in the nature of the job itself. But I want to call that mystifying assumption into question, to look directly at the issue of money as part of the praxis.

Hey there – apologies for the lighthearted reply above – I hadn’t been intending, if it came across this way, to dismiss the substantive question you’re asking – I’m still overseas and have very little time online at the moment, so one-line gnostic responses seem to be what I produce at the moment :-)

What you’ve said above, about focussing a practice around the issue of pathologies of the workplace, rather than the person situated in the midst of the workplace, reminded me of the work of Christophe Dejours – he has a similar focus (it might not be at all similar at the level of clinical practice – I’m not in a good position to know – but he has a long-term psychoanalytic focus on the psychodynamics of the workplace that has a similar (to my very untrained ear, at least) emphasis on conflicts between the person and a workplace that is the locus of pathology).

Apologies again for the scattershot posting – very interesting set of issues – apologies for not engaging in a more adequate way.

I see from your blog, N., that you’ve been busily on tour, which I hope is going well.

I’d not heard of Christophe Dejours. Either you’re a more proficient reader of French than I am, or else you’ve found some English-language source materials. From what I’ve been able to gather, Dejours brings a sociological focus on work stress, showing how the top-down corporate drive for efficiency and profitability induces fear, competitiveness and individual isolation in the employees. I think that’s right.

The work environment of my town is dominated by knowledge workers, academicians and entrepreneurial ventures. It’s regarded as a model town for the neoliberal American dream, where the Protestant bourgeois work ethic is augmented by more bohemian values of creativity and individual self-fulfillment. It’s been named by a leading business magazine as the “smartest town in America,” based largely on the high percentage of residents with advanced degrees. Its political orientation is generally liberal and green. But it’s also purportedly got the highest ratio of therapists per capita ratio in America. So either people don’t have enough else to worry about or else they’ve still got problems.

I understand that, from the rest of the world’s perspective, the immanent biopolitics of people like Hardt & Negri discount overmuch the possibility of outside resistance to Empire. But here in the heart of the Empire it seems that some kind of bottom-up emergence is the only possible source of resistance. I think work can be very important in contributing something to societal well-being and culture, but this possibility is thoroughly overridden by corporate profitability and individual satisfaction and buying power. Yet there remains (I hope) this persistent sense of the futility of it, of squandering one’s energy and creativity on worthless crap. So is there something I can do that gives voice to this sense of futility, that mounts some sense of resitance, individually and maybe also collectively, among the well-educated and affluent intellectual workers? That’s what I’m trying to explore.

So the issue of money as a measure of the value of one’s labor is I think central to what this sort of practice might entail. If an analyst holds a mirror in front of the client, maybe the analyst’s fees can also perform this mirroring function, inducing the person to reflect on how s/he values her/his work and how society values it.

I thought you might like this scheme Erdman. I can picture an accountant working on commission, agreeing to take some percentage of the tax deductions s/he finds for the client. I bet the higher the income, the more likely the person would be to understate earnings. If supply and demand is in play, then I’d most likely end up with low-income clients; the rich bastards would assume they could get equal quality services for a lower price elsewhere. Unless, of course, Freud’s Maxim is in play and people think they’re getting better service the more they pay.

Hey there – still on the run. In some ways, the tour goes too well: too many ideas, not enough “me” to incorporate them :-) Yes, Dejours may not have been translated much. There’s an audio of him speaking in English here, and some of the other papers at that same conference were about his work. Sorry not to say anything more substantive – my brain has reached the point where any new activity threatens a certain undesirable tipping point :-) Take care…

I listened to Dejours’ speech — he sounds like an organizational consultant. It seems that he’s trying to apply Axel Honneth’s ideas about interpersonal recognition in the workplace. I’d never heard of Honneth before either, but I read a little bit and it sounds like some possibly good stuff there. A market economist like Hayek is going to regard worker pay as recognition of value from the end user, but in a corporate setting when the distance between worker and customer is so great, payment is more a measure of status within the hierarchy than of value added. Stepping away from the money issue, though, I think Honneth and Dejours are right in that esteem, the sense of being valued for what one is able to achieve, is critical to satisfaction with one’s work. I’ll have to get back to the idea of recognition, maybe in another post.

It would be possible for a lot of psychotherapy to be done on a kind of barter system, like the AA buddy system. Someone who has had a problem and who has received support from someone as they worked through it could, after awhile, turn around and offer support to someone else. Evidence supports the contention that a lot of therapeutic benefit could be achieved by non-professionals dedicated to the task. S.W. Jackson (1999) says that what somebody in psychological distress needs most is access to someone who offers “a respectful and interested way of listening; a readily felt trustworthiness; a compassionate and sympathetic response to those who suffer; a capacity for arousing and sustaining hope; and a calm response to disturbing or frightening clinical states.” Some kind of interpersonally reciprocal offering of this sort of help to one another, through groups and one-on-one encounters, would achieve most of the gains in symptom relief that professional therapists achieve. It’s one reason why I’d rather cross into something more like analysis, where the goal isn’t necessarily to feel better but to arrive at greater self-understanding. The other stuff can be done for free by kinder, more supportive, more hopeful people than I.